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PITHINESS OF DATA OF THE NUTRITIVE STATUS IN PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME DURING NUTRITION SUPPORT
Girsh A.O., Maksimishin S.V.
Omsk State Medical University, City Clinical Hospital of Emergency Medical Care No.1, Omsk, Russia
Realization of nutritive support in patients with acute respiratory distress syndrome (ARDS) has some features and difficulties [1, 2]. Moreover, the diagnostic value of estimation criteria for protein and energy deficiency in patients with ARDS has not been estimated yet, resulting in obstacles for correct and adequate estimation of efficiency of techniques of clinical nutrition. As result, the objective of this study was to estimate pithiness of data of the nutritive status in patients with acute respiratory distress syndrome when carrying out various schemes of nutritious support.
MATERIALS AND METHODS
The
article presents the results of the studies of 198 patients (mean age of 29.7 ± 4.1) with ARDS (the table 1) treated in the ICU.
ARDS was diagnosed after 39 ± 6 hours in all patients on the basis [3]:
oxygenation index (OI = РаО2/FiO2), computer imaging of thoracic organs (presence of
non-homogenous infiltration in the lungs, especially in posterior-inferior
parts), a decrease in pulmonary tissue pneumatization by the type of frosted
glass, a decrease in mean value of optical density and an increase in optical
density in any chosen sections), X-ray examination (presence of bilateral
infiltrates in the lungs to the right and to the left), a risk factor (traumatic
shock of degrees 2-3), acute initiation (within 72 hours), absence of clinical
signs of left ventricular insufficiency. The inclusion criteria were: 1) age of
18-40; 2) mild, moderate or severe ARDS with need for stay in ICU; 3)
artificial lung ventilation (ALV) for patients with mild, moderate and severe
ARDS according to clinical guidelines of All-Russian public organization –
Federation of Anesthesiologists and Intensivists; 4) more than 72 hours in ICU;
5) presence of clinical and laboratory signs of nutritive insufficiency of any
severity. The exclusion criteria were: 1) contraindications for nutritive
support (absence of risk of development or signs of nutritive insufficiency,
refractory shock syndrome); 2) intolerance of media for enteral and parenteral
nutrition; 3) severe metabolic acidosis (pH of arterial blood < 7.2); 4)
severe arterial hypoxemia not corrected with ALV (PaO2 < 60 mm
Hg).
The clinical nutrition was initiated for all patients 74.5 ±
4.3 hours after admission to ICU. The indications for nutritive (enteral and/or
parenteral) support were [1]: 1) critical condition (ARDS after traumatic
shock); 2) ALV > 48 hours; 3) presence of hypermetabolism syndrome, which
determines the development of severe nutritive insufficiency. Severe nutritive
insufficiency was registered in all patients participating in the study (the
table 1). Enteral nutrition was conducted for patients with preserved
gastrointestinal functions [4-7]. Parenteral nutrition was realized for
patients with gastrointestinal dysfunction with impossibility for enteral
nutritive support [1, 4-7]. Mixed nutrition was prescribed for patients with
evident catabolism and preserved gastrointestinal functions [1, 6].
Table 1. Degrees of intensity of insufficient nutrition and used schemes of nutritive therapy for patients with ARDS
|
Groups of patients (n, %) with consideration of used nutritive therapy and values of nutritive status |
Mild ARDS (200 mm Hg < IO = PaO2/FiO2 ≤ 300 mm Hg), n (%) |
Average ARDS (100 mm Hg < IO = PaO2/FiO2 ≤ 200 mm Hg), n (%) |
Severe ARDS (IO = PaO2/FiO2 ≤ 100 mm Hg), n (%) |
|
Enteral nutrition |
|||
|
Group 1 (n = 75, 100 %) – Nutricomp Immun (B. Braun, Germany) |
22 (29.3 %) |
28 (37.4 %) |
25 (33.3 %) |
|
Parenteral nutrion |
|||
|
Group 2 (n = 66, 100 %) – three in one system Nutriflex 70/180 lipid (B. Braun, Germany) |
21 (31.8 %) |
23 (34.9 %) |
22 (33.3 %) |
|
Mixed (enteral and parenteral) nutrition |
|||
|
Group 3 (n = 57, 100 %) – Nutricomp Immun (B. Braun, Germany) + three in one system Nutriflex 70/180 lipid (B. Braun, Germany) |
19 (33.1 %) |
18 (31.6 %) |
20 (37 %) |
|
Total: 198 (100 %) |
62 (31.3 %) |
69 (34.9 %) |
67 (33.8 %) |
|
Nutritive status values |
|||
|
Albumin, g/l |
24 (23; 25) |
23 (22; 24) |
22 (20; 24) |
|
Transferrin, g/l |
1.5 (1.4; 1.6) |
1.4 (1.3; 1.5) |
1.3 (1.2; 1.5) |
|
Lymphocytes, cells per ml3 |
0.8 (0.7; 0.9) |
0.8 (0.7; 0.9) |
0.7 (0.5; 0.9) |
|
Energy requirements, kcal |
3076 (3010; 3247) |
3213 (3170; 3426) |
3580 (3396; 3624) |
The
parameters of nutrition insufficiency severity were determined [1]: albumin
(g/l) and transferrin (g/l) with the automatic analyzer Hitachi 902, Roche
Diagnostics (Switzerland). SysmexXT 4000i hematologic analyzer (Symex, USA) was
used for calculation of absolute number of lymphocytes (thousand per mcl) in
venous blood. Energetic requirement was estimated on the basis of indirect calorimetry
with MPR 6-03 (Triton, Russia) with function of metabolimeter. Body mass index
was calculated – BMI (kg/m2) = actual body mass (kg) / height (m2).
The diagnostic value of the studied indices determining the nutritive modality
degree was estimated with the following criteria. These criteria show the
operation characteristics of the studied parameters, which were calculated with
four-field tables (the table 2) [8]: 1. Sensitivity (%) (Se – proportion of
patients with this symptom (the positive result) or incidence of the symptom in
patients) = A/(A +C) x 100 %. 2. Specificity (%) (Sp – incidence of absence of
the symptom in healthy individuals) = D/(B + D) x 100 %. Efficiency of the method
(%) (the rate of false-positive results) of screening = 100 – SP (%). 4.
Predictive value positive (PVP – determined as incidence of coincidence with a
disease) = A/(A + B). 5. Predictive value negative (%) (PVN – determined as
incidence of coincidence with absence of a disease = D/(C + D).
Table 2. Estimation of diagnostic pithiness of data with use of four-field table
|
Outcomes |
Result of use of reference test for calculation of operational characteristics in qualitative estimation of value |
|
|
Poor |
A (true positive) |
B (false positive) |
|
Favorable |
C (false negative) |
D (true negative) |
The
study was conducted on the basis of approval from the bioethical committee of
City Clinical Hospital of Emergency Medical Care No.1 and corresponded to the
ethical standards of Helsinki Declare – Ethical Principles for Medical Research
with Human Subjects 2000, and the Rules for Clinical Practice in the Russian
Federation confirmed by the Order of Health Ministry of RF, 19 June 2003,
No.266.
RESULTS
The results of the study show that the key diagnostic criterion of nutritive insufficiency in patients with ARDS is energy requirement (the tables 3, 4, 5). Actually, this criterion is highly specific and sensitive, but also with low incidence of false-positive results, and with predictive value of positive results and low predictive value of negative results. Therefore, the use of the energy requirement value for estimation of severity of nutritive insufficiency is quite substantiated and statistically significant. The low percentage of substantiation of qualitative diagnosis of protein-energy insufficiency for patients with ARDS and the low incidence of coincidence with the studied disease, as compared to energy requirement value, were common for such parameters as albumin, transferrin and absolute number of lymphocytes (the table 3, 4, 5). Certainly, the use of these parameters as the main diagnostic signs of nutritive insufficiency in patients with ARDS is quite substantiated and statistically significant. Therefore, the use of this value for diagnosis of nutritive modality in patients with ARDS should be combined with estimation of energy requirement with aim of more objective estimation. BMI was irrelevant for intensity of protein-energy insufficiency in patients with ARDS (the tables 3, 4, 5). It was associated with the fact that this criterion had the low sensitivity and specificity in estimation of nutritive modality in patients with ARDS, and also had the high rate of false-positive results, low predictive value of positive results and high negative predictive value. As result, the use of BMI for estimation of nutritive insufficiency is quite inadequate and untrue.
Table 3. Findings of protein and energy deficiency in patients with enteral nutrition
|
Nutritive status in patients with mild ARDS |
Criteria |
||||
|
Sensitivity |
Specificity |
Price of
technique |
Prediction of favorable outcome (%) |
Prediction of poor outcome (%) |
|
|
1 г/g |
1 г/g |
1 г/g |
1 г/g |
1 г/g |
|
|
Albumin, g/l |
58.4 |
57.8 |
42.2 |
55.3 |
56.1 |
|
Transferrin, g/l |
61.3 |
60.9 |
39.1 |
59.7 |
58.4 |
|
Cell lymphocytes per mm3 |
55.7 |
56.4 |
43.6 |
57.2 |
54.5 |
|
Energy requirements, kcal |
87.8 |
85.8 |
14.2 |
83.5 |
81.4 |
|
BMI, kg/m2 |
33.7 |
36.2 |
63.8 |
34.5 |
35.7 |
|
Nutritive status in patients with moderate ARDS |
Criteria |
||||
|
Sensitivity |
Specificity |
Price of
technique |
Prediction of favorable outcome |
Prediction of poor
outcome |
|
|
2 г/g |
2 г/g |
2 г/g |
2 г/g |
2 г/g |
|
|
Albumin, g/l |
57.6 |
56.3 |
43.7 |
53.6 |
54.3 |
|
Transferrin, g/l |
60.6 |
61.4 |
38.6 |
58.2 |
56.9 |
|
Cell lymphocytes per mm3 |
53.6 |
54.7 |
45.3 |
55.4 |
53.7 |
|
Energy requirements, kcal |
86.2 |
87.7 |
13.3 |
85.8 |
84.6 |
|
BMI, kg/m2 |
32.3 |
34.5 |
65.5 |
33.7 |
34.8 |
|
Nutritive status in patients with severe ARDS |
Criteria |
||||
|
Sensitivity |
Specificity |
Price of technique (%) |
Prediction of favorable outcome |
Prediction of poor
outcome |
|
|
3 г/g |
3 г/g |
3 г/g |
3 г/g |
3 г/g |
|
|
Albumin, g/l |
56.4 |
55.9 |
44.1 |
54.7 |
55.2 |
|
Transferrin, g/l |
62.3 |
63.5 |
36.5 |
59.6 |
58.4 |
|
Cell lymphocytes per mm3 |
51.3 |
52.2 |
47.8 |
53.7 |
52.9 |
|
Energy requirements, kcal |
88.1 |
89.3 |
10.7 |
86.1 |
87.5 |
|
BMI, kg/m2 |
30.4 |
31.5 |
68.5 |
32.4 |
31.6 |
Table 4. Findings of protein and energy deficiency in patients with parenteral nutrition
|
Nutritive status in patients with mild ARDS |
Criteria |
||||
|
Sensitivity (%) |
Specificity (%) |
Price of
technique |
Prediction of favorable outcome |
Prediction of poor
outcome |
|
|
1 г/g |
1 г/g |
1 г/g |
1 г/g |
1 г/g |
|
|
Albumin, g/l |
57.2 |
56.3 |
43.7 |
54.6 |
55.4 |
|
Transferrin, g/l |
60.7 |
61.2 |
38.8 |
57.4 |
56,5 |
|
Cell lymphocytes per mm3 |
54.6 |
55.7 |
44.3 |
56.5 |
55.1 |
|
Energy requirements, kcal |
85.4 |
84.8 |
15.2 |
82.1 |
83.2 |
|
BMI, kg/m2 |
32.4 |
34.5 |
65.5 |
32.7 |
34.6 |
|
Nutritive status in patients with moderate ARDS |
Criteria |
||||
|
Sensitivity |
Specificity |
Price of
technique |
Prediction of favorable outcome |
Prediction of poor
outcome |
|
|
2 г/g |
2 г/g |
2 г/g |
2 г/g |
2 г/g |
|
|
Albumin, g/l |
56.5 |
55.8 |
44.2 |
55.7 |
54.8 |
|
Transferrin, g/l |
61.4 |
62.1 |
37.9 |
56.2 |
55.7 |
|
Cell lymphocytes per mm3 |
55.6 |
54.3 |
45.7 |
54.9 |
57.3 |
|
Energy requirements, kcal |
87.2 |
86.9 |
13.1 |
85.7 |
86.5 |
|
BMI, kg/m2 |
34.7 |
33.1 |
66.9 |
31.4 |
32.8 |
|
Nutritive status in patients with severe ARDS |
Criteria |
||||
|
Sensitivity |
Specificity |
Price of
technique |
Prediction of favorable outcome |
Prediction of poor
outcome |
|
|
3 г/g |
3 г/g |
3 г/g |
3 г/g |
3 г/g |
|
|
Albumin, g/l |
55.7 |
54.3 |
45.7 |
52.8 |
53.4 |
|
Transferrin, g/l |
60.2 |
61.7 |
38.3 |
55.9 |
54.2 |
|
Cell lymphocytes per mm3 |
54.1 |
53.7 |
46.3 |
52.8 |
53.7 |
|
Energy requirements, kcal |
88.1 |
87.4 |
12.6 |
87.1 |
88.2 |
|
BMI, kg/m2 |
33.3 |
32.5 |
67.5 |
32.5 |
31.3 |
Table 5. Findings of protein and energy deficiency in patients with mixed nutrition
|
Nutritive status in patients with mild ARDS |
Criteria |
|||||
|
Sensitivity |
Specificity |
Price of
technique |
Prediction of favorable outcome |
Prediction of poor
outcome |
||
|
1 г/g |
1 г/g |
1 г/g |
1 г/g |
1 г/g |
||
|
Albumin, g/l |
53.8 |
52.9 |
47.1 |
51.6 |
52.1 |
|
|
Transferrin, g/l |
61.4 |
62.3 |
37.7 |
57.1 |
56.9 |
|
|
Cell lymphocytes per ml3 |
52.7 |
51.3 |
48.7 |
50.4 |
51.2 |
|
|
Energy requirements, kcal |
89.6 |
88.7 |
11.3 |
89.2 |
87.4 |
|
|
BMI, kg/m2 |
31.6 |
32.1 |
67.9 |
30.3 |
30.7 |
|
|
Nutritive status in patients with moderate ARDS |
Criteria |
|||||
|
Sensitivity |
Specificity |
Price of
technique |
Prediction of favorable outcome |
Prediction of poor
outcome |
||
|
2 г/g |
2 г/g |
2 г/g |
2 г/g |
2 г/g |
||
|
Albumin, g/l |
52.4 |
51.7 |
48.3 |
50.6 |
51.1 |
|
|
Transferrin, g/l |
60.5 |
61.7 |
38.3 |
56.8 |
55.9 |
|
|
Cell lymphocytes per ml3 |
53.4 |
53.6 |
46.4 |
52.7 |
53.8 |
|
|
Energy requirements, kcal |
88.1 |
87.4 |
12.6 |
88.8 |
89.2 |
|
|
BMI, kg/m2 |
30.3 |
31.6 |
68.4 |
31.2 |
30.9 |
|
|
Nutritive status in patients with severe ARDS |
Criteria |
|
||||
|
Sensitivity |
Specificity |
Price of technique |
Prediction of favorable outcome |
Prediction of poor outcome |
||
|
3 г/g |
3 г/g |
3 г/g |
3 г/g |
3 г/g |
||
|
Albumin, g/l |
51.7 |
52.1 |
47.9 |
51.5 |
50.4 |
|
|
Transferrin, g/l |
61.2 |
62.4 |
37.6 |
55.7 |
55.1 |
|
|
Cell lymphocytes per ml3 |
52.9 |
51.7 |
48.3 |
51.5 |
52.6 |
|
|
Energy requirements, kcal |
89.3 |
88.7 |
11.3 |
89.4 |
89.8 |
|
|
BMI, kg/m2 |
31.5 |
30.7 |
69.3 |
31.8 |
32.1 |
|
DISCUSSION
The
high diagnostic significance of such parameter as energy requirement for
estimation of protein-energy deficiency in patients with ARDS was determined by
its pathogenetic features [2, 3], namely by development of systemic
inflammatory response, which significantly increases energy losses [1, 6].
Moreover, ARDS cause the negative energy balance by means of significant
breakdown and oxidation of glycogen and protein, and by means of intense lipolysis
[4, 5].
The
second (according to significance) estimation criterion of nutritive condition
was transferrin. It was associated with its level in vascular bed and with
short period of half-life (8 days) as compared to albumin (20 days) [1]. It
makes transferrin more sensitive criterion (as compared to albumin) in relation
to depletion of visceral pool of protein [4, 8]. However the transferrin level
highly depends on plasma level of iron and on organ and system disorders,
particularly on renal and hepatic insufficiency [1]. Moreover, significance of
estimation of transferrin is limited in hypoferric anemia, which exists before
or appears during the course of a disease, resulting in compensatory increase
in the blood even in conditions of protein deficiency [5].
The
time course of changes in serum albumin is insufficiently reliable for
estimation of adequacy of nutritive (both enteral and perenteral) support and
monitoring of time course of changes in nutritive modality [4, 5]. Moreover, the
plasma level of albumin depends on presence of organ and system disorders,
particularly, hepatic insufficiency [1, 7].
Absolute
amount of peripheral blood lymphocytes can be used for estimation of both
nutritive status and cellular link of immunity [1], which is the most
significant response to infection 72 hours after disease onset [4]. Moreover,
the synthesis of immune system cells, which are necessary for adequate response
to immune inflammation, requires the absence of evident protein and energy
deficiency [5]. Absolute amount of peripheral blood lymphocytes can be used as
a secondary parameter for estimation of nutritive status [1]. It is associated
with the fact that the absolute amount of lymphocytes in peripheral blood is
influenced by presence of renal and hepatic failure, electrolytic disorders,
infection, hypoalbuminemia, metabolic stress, chronic diseases, and use of
drugs for immune suppression action [4, 5].
Low
value of BMI for estimation of intensity of protein-energy insufficiency is
related to the fact that critically ill patients, particularly with ARDS, have
the fast and high body weight gain, which is determined by fluid retention
during fluid load [1, 4, 5].
CONCLUSION
1.
Correct diagnostic estimation of nutritive status in patients with ARDS
requires for estimation of energy requirement as the value with high
sensitivity and specificity, with use of adequate estimation of efficiency of
clinical nutrition in such patients.
2.
Transferrin, serum albumin and absolute amount of peripheral blood lymphocytes,
which are less informative, should be used for diagnostic estimation of
intensity of protein-energy deficiency in patients with ARDS as the secondary
criteria in combination with energy requirement.
3.
BMI cannot be used for patients with ARDS for estimation of nutritive modality
due to its low diagnostic value.
Information on financing and conflicts of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.
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